In yet another misalignment of profit and patient in America’s health care system, insurance status often determines whether a hospital emergency room transfers a patient to the higher-level care of a trauma center.
Ironically, hospital emergency rooms are much less likely to transfer patients who have insurance, placing financial concerns above the urgent needs of severely injured patients. Though most such patients are taken initially to trauma care, as many as one-third arrive at emergency rooms during the trauma patient’s critical “Golden Hour” where life hangs in the balance.
Dr. M. Kit Delgado, an emergency care research scholar at the University of Pennsylvania, led a study analyzing more than 4,500 trauma cases at more than 600 hospitals across the country, using data reported to the Department of Health and Human Services. Among findings, hospitals were 13 to 15 percent more likely to admit severely injured patients with insurance, suggesting a strong financial motive in snagging profitable patients.
"Insured patients may, ironically, get worse outcomes because they are taken care of at a center where there's a lower volume of resources for critically injured patients," Delgado said. "We hypothesize that non-trauma center hospitals are more likely to want to admit insured patients presumably because they can get reimbursed for their services.”
Those decisions are frequently a matter of life and death, too. Such patients are a 25 percent less likely to die at a level-1 trauma center — the highest level of care — as opposed to an emergency room, according to a 2006 study published in The New England Journal of Medicine. Although most local hospitals might suffice, level-1 trauma centers offer specialized medicine with dedicated surgeons, nurses, and technicians along with advanced medical equipment and a round-the-clock blood blank operation.
Dr. Nancy Wang, a senior author of the study and associate professor of medicine at Stanford, says the study is one of the first “population-level” analyses to uncover the truth about outcomes for severely injured patients taken first to the emergency room. A study last year from the University of Toronto even revealed another bias in decisions to transfer patients to higher level care, finding hospitals much less likely to transfer women than men. Analyzing data from 100,000 Canadian patients, the investigators found a statistically significant difference non-elderly patients with 49.6 percent of severely injured women receiving higher-level care compared to 63.2 percent of men.
When examining only insurance status in this new study, however, investigators also found disparities in care among children, the elderly, and those brought to urban teaching hospitals. "Finding disparities in quality of trauma care based on insurance is very disturbing," Wang said. "It is important for researchers to identify and call attention to these disparities in access to care and outcomes so that all people can receive the appropriate, high-quality care regardless of their insurance status."
As for solutions, the Stanford investigators suggest greater oversight of emergency rooms to ensure severely injured patients receive the most appropriate care no matter the cost considerations. Financial conflicts might also be eliminated by devising cost-sharing schemes between hospitals and trauma centers, given the obvious worth of such higher-level care. "Study after study has shown that the more patients that a trauma team takes care of, the more experience they get — and their outcomes are going to be better," Delgado said.
Although the American College of Surgeons oversees trauma care centers across the country and enumerates procedural rules for emergency room doctors, many clinicians fail to adhere to guidelines for trauma care transfers, according to a study from the University of Pittsburgh.
"Some of it has to do with failure to identify which conditions would do better at a trauma center, and some of it has to do with practice patterns — what the hospital is used to taking care of on its own, " Delgado said.
Investigators next plan to study whether trauma patients with health insurance experience worse outcomes than the uninsured. The study was published in JAMA Surgery.